Epidemiology and Health

Most-download articles are from the articles published in 2023 during the last three month.

Original Article

Sugar-sweetened beverage consumption and metabolic dysfunction-associated steatotic liver disease: a beverage type-specific analysis using Korea National Health and Nutrition Examination Survey: Hong Jae Jeon, Woo Sun Rou, Seok Hyun Kim, Byung Seok Lee, Ha Neul Kim, Hei-Gwon Choi, Jaehee Seo, Hyuk Soo Eun, Sukyoung Jung; Epidemiol Health. 2025;47:e2025038. Published online July 21, 2025; DOI: https://doi.org/10.4178/epih.e2025038

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent liver disease. Evidence indicates a relationship between sugar-sweetened beverage (SSB) consumption and MASLD development; however, the effects of specific SSB types on MASLD remain underexplored. This study investigated the association between consumption of 3 distinct types of SSBs and MASLD in Korean adults.
METHODS
We analyzed data from the Korea National Health and Nutrition Examination Survey 2012-2016, including 8,310 participants aged 40-64 years. SSB consumption (soft drinks, fruit drinks, and Korean traditional drinks) was assessed using a food frequency questionnaire. MASLD was defined as a hepatic steatosis index ≥36 in the presence of any cardiometabolic risk factor. Logistic regression models were used to estimate odds ratios (ORs) with 95% confidence intervals (CIs), adjusting for relevant covariates.
RESULTS
Compared to non-drinkers, consumption of soft drinks (≥3 serving/wk) was associated with higher odds of MASLD (OR, 1.36; 95% CI, 1.02 to 1.81; p for trend=0.03), while consumption of Korean traditional drinks (≥3 serving/wk) was associated with lower odds of MASLD (OR, 0.63; 95% CI, 0.45 to 0.89; p for trend=0.01). No association was found between fruit drink consumption and MASLD. In sex-stratified analysis (p-interaction=0.38), an inverse association between Korean traditional drinks and MASLD was observed in male (OR, 0.57; 95% CI, 0.34 to 0.95; p for trend=0.03), but not in female (OR, 0.72; 95% CI, 0.45 to 1.14; p for trend=0.17).
CONCLUSIONS
Consuming soft drinks at least 3 times per week was positively associated with MASLD, whereas an equivalent intake of Korean traditional drinks was inversely associated with MASLD.; Summary

Korean summary
-본 연구는 국민건강영양조사에 참여한 40-64세 한국 성인 8,310명을 대상으로 가당 음료와 새롭게 정의된 대사기능장애 연관 지방간질환(MASLD) 간 연관성을 음료 유형별로 비교 분석하였다. - 주 3회 이상의 탄산음료 섭취는 MASLD 유병 가능성이 증가한 반면, 동일한 빈도의 한국 전통음료 섭취는 유병 가능성을 낮췄다. - 음료 유형에 따른 MASLD 유병 차이는 향후 식이 지침 개발에 중요한 근거가 될 수 있으며, 향후 개인이 건강을 위해 보다 선택적인 음료 섭취를 위한 정책 수립에 기여할 수 있다.

Key Message
Among 8,310 Korean adults aged 40-64 years, soft drink consumption (≥3 servings/week) increased the odds of MASLD, while the same intake of Korean traditional drinks decreased the odds. These findings suggest that beverage type may be an important dietary factor associated with MASLD. Given the differential associations observed, our findings may help inform dietary recommendations that enable individuals to make more selective beverage choices for better liver health.

Erratum

Characteristics of imported and domestic malaria cases in Gyeonggi Province, Korea: Sunghee Hong, Jihye Kim, Soo-Nam Jo, Jong-Hun Kim, Boyoung Park, Bo Youl Choi; Epidemiol Health. 2025;47:e2024087.E. Published online March 17, 2025; DOI: https://doi.org/10.4178/epih.e2024087.E; Corrects: Epidemiol Health 2024;46:e2024087

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PDF: Abstract; Summary

Original Article

Health literacy in Korea: findings from the 2023 Korea National Health and Nutrition Examination Survey: Sunhye Choi, Yukyeong Kang, Hyejin Kim, Kyungwon Oh; Epidemiol Health. 2025;47:e2025037. Published online July 9, 2025; DOI: https://doi.org/10.4178/epih.e2025037

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Abstract Summary PDF: Abstract
OBJECTIVES
This study aimed to assess health literacy and identify vulnerable groups, providing a basis for developing health policies aimed at improving health literacy, using data from the 2023 Korea National Health and Nutrition Examination Survey (KNHANES).
METHODS
The health literacy measurement tool used in the 2023 KNHANES comprised a total of 10 items spanning the domains of disease prevention, health promotion, healthcare, and technology and resources. Health literacy was analyzed in relation to socio-demographic characteristics and major health behaviors among 5,906 adults aged 19 years or older, using the SAS program.
RESULTS
As of 2023, the overall prevalence of adequate health literacy among adults was 60.4%. Adequate health literacy was higher in women (62.2%) than in men (58.6%). Younger individuals exhibited higher levels of health literacy, with those aged 19–64 years at 65.9%, compared to only 40.3% among those aged 65 or older. Higher income and education levels were also associated with greater health literacy. Regarding health behavior characteristics, individuals practicing healthy lifestyles, such as non-smoking, engaging in physical activity, and undergoing health checkups, demonstrated higher health literacy than those who did not engage in such behaviors.
CONCLUSIONS
Six out of 10 Korean adults demonstrated adequate health literacy, but significant differences were observed according to socio-demographic characteristics (e.g., age and education) and health behaviors (e.g., smoking and physical activity). Tailored education and policy initiatives are necessary to improve health literacy, particularly targeting older adults, low-income groups, individuals with lower education, and those who do not practice healthy lifestyles.; Summary

Korean summary
2023년 국민건강영양조사를 통해 우리 국민의 건강정보이해능력을 처음으로 조사한 결과, 우리나라 성인 10명 중 6명은 적절한 건강정보이해능력을 갖고 있었다. 건강정보이해능력은 고령, 낮은 교육수준, 건강생활 비실천 등에서 낮아 취약군의 건강정보이해능력 향상을 위한 맞춤형 교육과 정보 제공 등 다양한 방안 모색이 필요하다.

Key Message
According to the results of the 2023 KNHANES—the first nationwide assessment of health literacy in Korea—6 out of 10 Korean adults had adequate health literacy. Diverse strategies—including targeted education and information provision—are needed to improve health literacy among vulnerable groups such as older adults, those with low education and individuals who do not practice healthy lifestyles.

Special Article

Cancer risk based on alcohol consumption levels: a comprehensive systematic review and meta-analysis: Seunghee Jun, Hyunjin Park, Ui-Jeong Kim, Eun Jeong Choi, Hye Ah Lee, Bomi Park, Soon Young Lee, Sun Ha Jee, Hyesook Park; Epidemiol Health. 2023;45:e2023092. Published online October 16, 2023; DOI: https://doi.org/10.4178/epih.e2023092

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29 Web of Science
32 Crossref

Abstract Summary PDF Supplementary Material

Abstract

OBJECTIVES
Alcohol consumption is a well-established risk factor for cancer. Despite extensive research into the relationship between alcohol consumption and cancer risk, the effect of light alcohol consumption on cancer risk remains a topic of debate. To contribute to this discourse, we conducted a comprehensive systematic review and meta-analysis.

METHODS

Our systematic review aimed to investigate the associations between different levels of alcohol consumption and the risk of several cancer types. We focused on analyzing prospective associations using data from 139 cohort studies. Among them, 106 studies were included in the meta-analysis after a quantitative synthesis.

RESULTS

Our analysis did not find a significant association between light alcohol consumption and all-cause cancer risk (relative risk, 1.02; 95% confidence interval, 0.99 to 1.04), but we observed a dose-response relationship. Light alcohol consumption was significantly associated with higher risks of esophageal, colorectal, and breast cancers. Light to moderate drinking was associated with elevated risks of esophageal, colorectal, laryngeal, and breast cancers. Heavy drinking was also found to contribute to the risk of stomach, liver, pancreas, and prostate cancers, thereby increasing the risk of almost all types of cancer. Additionally, females generally had lower cancer risks compared to males.

CONCLUSIONS

Our findings highlight that cancer risks extend beyond heavy alcohol consumption to include light alcohol consumption as well. These findings suggest that there is no safe level of alcohol consumption associated with cancer risk. Our results underscore the importance of public health interventions addressing alcohol consumption to mitigate cancer risks.

Summary

Korean summary
본 연구는 코호트 연구를 기반으로 하여 음주의 수준에 따른 암 위험 연관성에 대해 체계적 문헌고찰(139편)과 메타분석(106편)을 수행하였다. 연구 결과, 음주와 암 위험 사이에 용량-반응 관계가 나타났으며, 소량의 음주는 암 유형에 따라 차이가 있었으나, 식도암, 대장암, 전립선암(남성), 유방암(여성)에서 암 위험과의 연관성이 있음을 발견했다. 따라서, 암 위험 측면에서 음주에 안전한 수준이 없음을 시사하며, 음주와 관련된 잠재적 피해를 완화하기 위해서는 음주 지침 강화와 같은 공중보건개입이 필요하다.

Key Message
The aim of this study was to assess the relationship between different levels of alcohol consumption and the risk of various cancer types through a systematic review and meta-analysis, providing insights into the ongoing debate about alcohol consumption and cancer causality. The findings support a dose-response relationship between alcohol consumption levels and cancer risk and the light alcohol consumption was associated with risks of esophageal, colorectal, prostate (male), and breast (female) cancer. These results emphasize the absence of a safe threshold for alcohol consumption in terms of cancer risk.

Citations

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Original Articles

Socioeconomic inequality in organized and opportunistic screening for breast cancer: results from the Korean National Cancer Screening Survey, 2009-2021: Yejin Ha, Xuan Quy Luu, Woorim Kim, Jae Kwan Jun, Mina Suh, Kui Son Choi; Epidemiol Health. 2025;47:e2025031. Published online May 30, 2025; DOI: https://doi.org/10.4178/epih.e2025031

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
Breast cancer screening rates have increased since the introduction of the National Cancer Screening Program (NCSP) in Korea. However, it remains unclear whether socioeconomic inequalities have improved, particularly according to screening type. This study investigated inequalities in organized (government-led) and opportunistic (individually initiated) screening, stratified by education and income levels.
METHODS
Data were obtained from the Korean National Cancer Screening Survey, conducted annually from 2009 to 2021, involving approximately 1,700 women each year except in 2009. Trends were analyzed using joinpoint regression to calculate average annual percent changes (AAPCs). Socioeconomic inequalities were assessed using the slope index of inequality (SII) and relative index of inequality (RII).
RESULTS
Organized screening rates increased from 42.0% in 2009 to 60.2% in 2021 (AAPC, 1.9; 95% confidence interval [CI], 0.7 to 3.4), whereas opportunistic screening rates declined from 13.3% to 11.2% (AAPC, -5.4; 95% CI, -8.7 to -2.3). For organized screening, individuals with lower education levels exhibited higher participation, resulting in negative inequality indices (SII, -5.37%; RII, 0.80). No significant income-based inequality was found (SII, 1.60%; RII, 1.07). However, opportunistic screening demonstrated significant inequalities by both education (SII, 5.37%; RII, 1.92) and income (SII, 5.90%; RII, 1.96), with higher participation rates among more advantaged groups.
CONCLUSIONS
The NCSP has improved breast cancer screening rates and reduced income-related inequality in organized screening. However, educational and income-based inequalities persist in opportunistic screening. To reduce screening inequities, policy efforts are needed to further promote the NCSP, including improving program quality and providing financial support for follow-up examinations.; Summary

Korean summary
본 연구는 한국의 유방암 검진에서 검진 유형에 따른 사회경제적 불평등을 분석하였다. 국가 검진에서는 전체 수검률이 증가하고 소득 관련 불평등이 감소한 반면 개인 검진에서는 사회경제적 불평등이 여전히 존재하였다. 유방암 검진의 불평등을 줄이기 위해 지속적이고 집중적인 정책 노력이 필요하다.

Key Message
This study examined socioeconomic inequality in breast cancer screening in Korea by screening type. While organized screening has improved overall participation and reduced income-related inequality, socioeconomic inequalities remain in opportunistic screening. Continued and targeted policy efforts for the NCSP are necessary to further reduce inequality in breast cancer screening.

Safety of combination therapy of azilsartan medoxomil and amlodipine: a population-based cohort study: Hyesung Lee, Bin Hong, Chris Tzu-Ting Su, Sungho Bea, Han Eol Jeong, Kyungyeon Jung, Michael Chun-Yuan Cheng, Zoe Chi-Jui Chang, Edward Chia-Cheng Lai, Jongyoung Lee; Epidemiol Health. 2025;47:e2025029. Published online May 28, 2025; DOI: https://doi.org/10.4178/epih.e2025029

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
This study investigated the safety of azilsartan and amlodipine combination therapy versus other angiotensin receptor blockers (ARBs) and amlodipine in patients with hypertension.
METHODS
We conducted a cohort study utilizing healthcare databases from Korea and Taiwan. Patients aged between 18 years and 75 years who were newly prescribed both an ARB and amlodipine within 6 months of hypertension diagnosis were included. Safety outcomes assessed were hypotension, angioedema, acute pancreatitis, hyperkalemia, hypokalemia, toxic liver disease, hepatic failure, nausea and vomiting, and fall-related injury. Hazard ratios (HRs) with 95% confidence intervals (CIs) for each safety outcome associated with azilsartan medoxomil and amlodipine versus other ARBs combined with amlodipine were calculated within a 1:1 propensity score (PS)-matched cohort. Summary HRs across databases were computed using random-effects meta-analysis.
RESULTS
We identified 2,472 eligible patients (1,521 from Korea, 951 from Taiwan) initiating treatment with azilsartan medoxomil and amlodipine, and 671,468 patients (312,322 from Korea, 355,409 from Taiwan) initiating other ARBs with amlodipine. After PS matching, baseline characteristics were well-balanced between treatment groups. During the 180-day follow-up, most adverse outcomes did not occur even once in either group, thus precluding the calculation of HRs. The risk of acute pancreatitis was not significantly different between the azilsartan medoxomil and amlodipine group and the other ARB and amlodipine groups (summary HR, 0.86; 95% CI, 0.14 to 5.37).
CONCLUSIONS
In this population-based cohort study, azilsartan medoxomil combined with amlodipine was not associated with an increased risk of adverse outcomes compared to other ARBs combined with amlodipine.; Summary

Korean summary
Azilsartan medoxomil과 amlodipine 병용요법의 장기적인 안전성을 평가한 연구는 제한적임. 본 코호트 연구에서는 azilsartan과 amlodipine 병용요법이 다른 ARB-amlodipine 병용요법에 비해 중대한 이상반응 발생 위험을 증가시키지 않는 것으로 나타났음. 이러한 결과는 고혈압 환자에서 azilsartan-amlodipine 병용요법의 실제 진료 환경에서의 안전성을 뒷받침함.

Key Message
Limited studies have evaluated the long-term safety of combined azilsartan medoxomil and amlodipine therapy. This cohort study found the azilsartan and amlodipine combination therapy was not associated with increased risk of serious adverse events compared to other ARB-amlodipine combinations. These results support the real-world safety of azilsartan-amlodipine caombination therapy in patients with hypertension.

Identifying adverse reactions following COVID-19 vaccination in Korea using data from active surveillance: a text mining approach: Hye Ah Lee, Bomi Park, Chung Ho Kim, Yeonjae Kim, Hyunjin Park, Seunghee Jun, Hyelim Lee, Seunghyun Lewis Kwon, Yesul Heo, Hyungmin Lee, Hyesook Park, COVID-19 Vaccine Safety Research Committee; Epidemiol Health. 2025;47:e2025034. Published online June 30, 2025; DOI: https://doi.org/10.4178/epih.e2025034

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
Unstructured text data collected through vaccine safety surveillance systems can identify previously unreported adverse reactions and provide critical information to enhance these systems. This study explored adverse reactions using text data collected through an active surveillance system following coronavirus disease 2019 (COVID-19) vaccination.
METHODS
We performed text mining on 2,608 and 2,054 records from 2 survey seasons (2023-2024 and 2024-2025), in which participants reported health conditions experienced within 7 days of vaccination using free-text responses. Frequency analysis was conducted to identify key terms, followed by subgroup analyses by sex, age, and concomitant influenza vaccination. In addition, semantic network analysis was used to examine terms reported together.
RESULTS
The analysis identified several common (≥1%) adverse events, such as respiratory symptoms, sleep disturbances, lumbago, and indigestion, which had not been frequently noted in prior literature. Moreover, less frequent (≥0.1 to <1.0%) adverse reactions affecting the eyes, ears, and oral cavity were also detected. These adverse reactions did not differ significantly in frequency based on the presence or absence of simultaneous influenza vaccination. Co-occurrence analysis and estimation of correlation coefficients further revealed associations between frequently co-reported symptoms.
CONCLUSIONS
This study utilized text mining to uncover previously unrecognized adverse reactions associated with COVID-19 vaccination, thereby broadening our understanding of the vaccine’s safety profile. The insights obtained may inform future investigations into vaccine-related adverse reactions and improve the processing of text data in surveillance systems.; Summary

Korean summary
* 본 연구는 COVID-19 백신 접종 후 자가 보고된 증상을 텍스트 마이닝으로 분석하여, 이전에 알려지지 않았던 부작용을 확인하였습니다. * 본 연구 결과는 백신 부작용에 대한 이해를 높이고, 향후 연구 및 감시 체계 개선에 중요한 통찰력을 제공합니다.

Key Message
* This study used text mining of self-reported symptoms following COVID-19 vaccination to identify previously unrecognized adverse reactions. * Our findings enhance the understanding of vaccine side effects and provide valuable insights for future research and surveillance system improvement.

Systematic Review

The effectiveness of protein supplementation combined with resistance exercise programs among community-dwelling older adults with sarcopenia: a systematic review and meta-analysis: Phatcharaphon Whaikid, Noppawan Piaseu; Epidemiol Health. 2024;46:e2024030. Published online February 14, 2024; DOI: https://doi.org/10.4178/epih.e2024030

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Abstract Summary PDF

Abstract

OBJECTIVES
The combination of protein supplementation and resistance exercise shows promise for improving and maintaining muscle mass, strength, and performance in older adults with sarcopenia. This systematic review aimed to evaluate the effects of this combination on muscle mass, muscle strength, and physical performance in community-dwelling older adults with sarcopenia.

METHODS

We conducted a comprehensive search of 4 electronic databases: PubMed, Scopus, Embase, and the MEDLINE Library. The search covered literature from January 2013 to January 2023 and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two independent reviewers assessed the methodological quality of each study using the standard critical appraisal tool from the Joanna Briggs Institute (JBI). Meta-analysis was performed with the JBI Sumari program.

RESULTS

The review included 7 randomized controlled trials and 1 quasi-experimental study, encompassing a total of 854 participants aged 60 years and above. The study durations ranged from 10 weeks to 24 weeks. An analysis of standardized mean differences (SMDs) showed that protein supplementation combined with resistance exercise significantly increased muscle mass (SMD, 0.95; 95% confidence interval [CI], 0.13 to 1.78; p<0.05) and muscle strength (SMD, 0.32; 95% CI, 0.08 to 0.56; p<0.05).

CONCLUSIONS

Although the limited number of randomized controlled trials restricts the robustness of our conclusions, the evidence suggests that protein supplementation combined with resistance exercise is effective in enhancing muscle mass and strength in community-dwelling older adults with sarcopenia.

Summary

Key Message
Sarcopenia is a significant health concern. Given the contextual variations and the diverse factors that contribute to the prevalence of sarcopenia, delivering precision interventions to older adults diagnosed with sarcopenia who still reside in the community poses unique challenges. Therefore, precision interventions are vital for proper and feasible treatment planning, especially for early management actions, to reduce the impact of sarcopenia and its associated adverse effects in older adults. Our systematic review and meta-analysis showed that protein supplementation combined with resistance exercise is effective in enhancing muscle mass and strength in community-dwelling older adults with sarcopenia.

Citations

Citations to this article as recorded by

Protein supplementation alone or combined with exercise for sarcopenia and physical frailty: A systematic review and meta-analysis of randomized controlled trials
Yoshihiro Yoshimura, Ayaka Matsumoto, Tatsuro Inoue, Masatsugu Okamura, Masafumi Kuzuya
Archives of Gerontology and Geriatrics.2025; 131: 105783. CrossRef
The diagnosis and treatment of sarcopenia and sarcopenic obesity
Basel Habboub, Robert Speer, Markus Gosch, Katrin Singler
Deutsches Ärzteblatt international.2025;[Epub] CrossRef
Osteosarcopenia as a risk factor for depression: Longitudinal findings from the SHARE study
Nicola Veronese, Francesco Saverio Ragusa, Shaun Sabico, Ligia Juliana Dominguez, Mario Barbagallo, Gustavo Duque, Lee Smith, Nasser Al-Daghri
Bone Reports.2025; 25: 101848. CrossRef
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Nikolaos Schörghofer, Christoph Knapitsch, Gretha Hecke, Nikolaus Clodi, Lucas Brandstetter, Crispiana Cozowicz, Matthias Hammerer, Klaus Hergan, Uta C. Hoppe, Bernhard Scharinger, Elke Boxhammer
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Julian Kylies, Tobias Malte Ballhause, Jana Striefler, Dominik Kylies, Matthias Priemel
European Journal of Surgical Oncology.2025; 51(9): 110293. CrossRef
Sarcopenic obesity in the Asia-Pacific region: Epidemiology, risk factors, and management
Chun-Feng Huang, Chih-Hsing Wu
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Sarcopenia is associated with increased hip fracture risk among middle-aged and elderly Chinese adults in longitudinal analysis of CHARLS data
Sensen Huang, Le Chang, Zhenyu Cai
Scientific Reports.2025;[Epub] CrossRef
Symphony of regulated cell death: Unveiling therapeutic horizons in sarcopenia
Jie Peng, Mi Zou, Qianmingyue Zhang, Dongcan Liu, Shuanghong Chen, Ruiying Fang, Yuan Gao, Xiaohua Yan, Liang Hao
Metabolism.2025; 172: 156359. CrossRef
Exercise and Nutrition for Sarcopenia: A Systematic Review and Meta-Analysis with Subgroup Analysis by Population Characteristics
Yong Yang, Neng Pan, Jiedan Luo, Yufei Liu, Zbigniew Ossowski
Nutrients.2025; 17(14): 2342. CrossRef
Formulation, Phytochemical Characterization, and Clinical Assessment of a Novel Natural Supplement Targeting Body Composition in Physically Active Individuals: A Randomized Clinical Trial
Tablo Azad Hama salih, Halgord Ali M. Farag
Kurdistan Journal of Applied Research.2025; 10(2): 12. CrossRef
Food-derived bioactive compounds targeting mitophagy: Emerging nutritional strategies against sarcopenia
Haozhen Zhang, Laiming Zhang, Donghong Liu, Xingqian Ye, Shiguo Chen
Trends in Food Science & Technology.2025; 165: 105314. CrossRef
Assessing the risk of sarcopenia among community-dwelling older adults in Israel: a national cross-sectional survey
Miri Lutski, Ziv Karni-Efrati, Inbar Zucker, Dvora Frankenthal
European Geriatric Medicine.2025;[Epub] CrossRef
The Impact of Protein in Post-Menopausal Women on Muscle Mass and Strength: A Narrative Review
Katherine Elizabeth Black, Penelope Matkin-Hussey
Physiologia.2024; 4(3): 266. CrossRef

COVID-19: Cohort Profile

Cohort profile: Cardiovascular Metabolic Etiological Research Center COVID-19 Mental Health Survey (CC-MHS): Sun Jae Jung, Dongkyu Lee, Ji Su Yang, Sunghyuk Kang, Hyejin Kim, Jeong Hyun Ahn, Yunseong Heo, Jieun Noh, Changhyun Kim, Hyeon Chang Kim; Epidemiol Health. 2025;47:e2025033. Published online June 30, 2025; DOI: https://doi.org/10.4178/epih.e2025033

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Abstract Summary PDF: Abstract
The Cardiovascular Metabolic Etiological Research Center COVID-19 Mental Health Survey (CC-MHS) is a comprehensive longitudinal cohort study investigating the mental health impact of the coronavirus disease 2019 pandemic by utilizing pre-existing baseline data from the Cardiovascular Metabolic Etiological Research Center cohort (2013-2018). This study assesses physical health, lifestyle changes, and mental health using validated tools, including the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and the PTSD Checklist for DSM-5, and evaluates a population of urban and suburban Korean participants across multiple dimensions. Through online surveys, the research identified gender-specific social support mechanisms, showing that men benefit from larger social networks, whereas women derive protective effects from stronger emotional connections. Key findings underscore complex interactions among demographic factors, psychological variables, and public health responses, especially in the context of vaccination attitudes and trust in pandemic management. The CC-MHS delivers critical insights into mental health trajectories during global health crises, offering valuable evidence for developing adaptive public health strategies and for understanding the intricate relationships between individual psychological resilience and broader societal health challenges.; Summary

Korean summary
본 CC-MHS 코호트는 팬데믹 이전 4,060명 대상 CMERC 기초자료 활용하였다 본 CC-MHS 코호트는 우울, 불안, PTSD 등 정신건강 평가를 7차례 추적조사하였다. 본 코호트에서는 성별 보호요인과 사회적 지지·신뢰의 중요성 규명하였다.

Key Message
In CC-MHS, we utilized pre-pandemic baseline data from 4,060 adults in the CMERC cohort. We conducted 7 waves of mental health surveys assessing depression, anxiety, PTSD, and resilience. In this cohort, we identified gender-specific protective factors and emphasized the importance of social support and trust.

Original Articles

Being trans in Korea: key milestones and stigmatization across life stages in a nationwide survey of 585 transgender and non-binary young adults: Sungsub Choo, Ranyeong Kim, Hyemin Lee, Horim Yi, Rockli Kim, Seung-Sup Kim; Epidemiol Health. 2025;47:e2025032. Published online June 27, 2025; DOI: https://doi.org/10.4178/epih.e2025032

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
Understanding the experiences of transgender and non-binary (TGNB) individuals from a life-course perspective is essential. This article aims to identify ages at key milestones related to transgender identity and assess experiences of stigmatization among TGNB individuals across different life stages.
METHODS
We analyzed data from a nationwide longitudinal survey of 585 TGNB adults in Korea collected in 2020 and 2021. Analysis of variance and chi-square test were used to compare mean ages at transgender identity developmental milestones and experiences of anti-transgender stigma across transgender identities.
RESULTS
On average, TGNB Koreans realized their transgender identity at age 13, accepted it at age 20, and came out to others at age 21. Regarding experiences of stigmatization across different life stages, 67.4% reported hearing homophobic and transphobic remarks from teachers in secondary school. Among TGNB individuals assigned male at birth (AMAB) who served mandatory military service, 29.0% were classified as maladjusted soldiers, and 12.1% experienced sexual harassment or violence. When asked about the job application process, 57.0% reported discontinuing their job search due to their transgender identity. Financial burden represented the primary barrier to psychiatric evaluations, hormone treatment, and gender-affirming surgery.
CONCLUSIONS
Our study identifies key milestone ages related to transgender identity and experiences of stigmatization across life stages among TGNB adults in Korea. With 97.6% of participants under 40 years old, these findings primarily reflect the experiences of TGNB young adults. Further research is necessary to better understand the experiences of middle-aged and elderly TGNB individuals in Korea.; Summary

Korean summary
한국에서 트랜스젠더 당사자들은 평균적으로 13살에 트랜스젠더 정체성을 자각하고, 20살에 트랜스젠더로서의 자신을 수용하며, 21살에 처음으로 트랜스젠더 정체성을 타인에게 알린다. 시스젠더 이성애자의 몸을 표준으로 구성된 한국 사회에서, 트랜스젠더는 청소년기와 성인기를 거치며 고등학교, 군 복무, 취업, 의료 이용 등에서 차별과 낙인을 경험한다.

Key Message
The average age of developmental milestones related to transgender identity include realizing their transgender identity at age 13, accepting it at age 20, and first coming out at age 21. TGNB individuals faced stigma and discrimination in key set- tings and situations such as secondary school, the military, and job applications from their adolescence and onwards.

Spatial patterns of laboratory-confirmed leptospirosis in north-eastern Peninsular Malaysia, 2016-2023: Hazlienor Mohd Hatta, Kamarul Imran Musa, Nik Mohd Hafiz Mohd Fuzi, Paula Moraga; Epidemiol Health. 2025;47:e2025030. Published online May 29, 2025; DOI: https://doi.org/10.4178/epih.e2025030

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
Leptospirosis presents significant public health challenges in endemic regions such as north-eastern Peninsular Malaysia. Spatial analysis is essential for visualising disease incidence and distribution, assessing vulnerability based on geographical and socioeconomic factors, and ultimately informing targeted interventions, optimising resource allocation, and enhancing surveillance strategies. This study aimed to determine the incidence and characterise the spatial distribution of leptospirosis in Kelantan, Malaysia.
METHODS
All laboratory-confirmed leptospirosis cases reported in Kelantan between 2016 and 2023 were extracted from the Communicable Disease Control Information System e-Notifikasi online database. Spatial analyses were performed using the spatstat, spdep, and ggplot2 packages within the RStudio integrated development environment.
RESULTS
The analysis encompassed 1,534 laboratory-confirmed leptospirosis cases. The average crude annual incidence of leptospirosis cases per 1,000 population from 2016 to 2023 was 0.101 (95% confidence interval, 0.038 to 0.164). Incidence varied considerably across districts and subdistricts, initially higher in the north but declining over time, while consistently high and increasing incidence was observed in the southern region. Significant clustering of leptospirosis cases occurred throughout the studied years, except during the coronavirus disease 2019 pandemic. Hotspots were initially prevalent in northern areas but later emerged in south-eastern and southern regions. Significant spatial autocorrelation evolved from high-low to high-high clusters, particularly evident in central and southern regions.
CONCLUSIONS
This study provides valuable local epidemiological and spatial insights into the endemicity of leptospirosis. The findings highlight the need for targeted interventions and continued surveillance to effectively mitigate the leptospirosis burden in endemic areas.; Summary

Key Message
• This study examined leptospirosis patterns in Kelantan, Malaysia, from 2016 to 2023, highlighting distinct regional varia- tions in disease incidence. • Case densities were high in the northern region, whereas incidence demonstrated higher risk in the central and southern regions. • The study underscores the importance of considering both geographic location and population dynamics when planning interventions and allocating resources for disease control. • The evident spatial clustering highlights the need for targeted public health interventions.

Mortality burden attributable to long-term exposure to fine particulate matter among older adults in Korea: Jongmin Oh, Jisun Myung, Changwoo Han, Hyun-Joo Bae, Soontae Kim, Yun-Chul Hong, Dong-Wook Lee, Youn-Hee Lim; Epidemiol Health. 2025;47:e2025028. Published online May 28, 2025; DOI: https://doi.org/10.4178/epih.e2025028

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
This study aimed to evaluate the association between long-term exposure to particulate matter with an aerodynamic diameter <2.5 μm (PM2.5) and cause-specific mortality among older adults in Korea, providing insights into the evolving public health burden in an aging society.
METHODS
We analyzed national insurance claims data spanning 2010-2019. Modeled PM2.5 concentrations were assigned to participants according to their residential districts. We employed time-varying Cox proportional hazard models, using age as the time scale, adjusted for potential confounders. Six cause-specific mortalities were considered: ischemic heart disease (IHD), stroke, chronic obstructive pulmonary disease (COPD), acute lower respiratory infection (ALRI), lung cancer (LC), and type 2 diabetes mellitus (T2DM). Annual excess deaths attributable to long-term PM2.5 exposure were calculated.
RESULTS
A total of 5,360,032 older adults were followed from 2010 to 2019. Hazard ratios (HRs) per 10 μg/m3 increase in 12-month PM2.5 concentration were as follows: IHD, 1.068 (95% CI, 1.040 to 1.097); stroke, 1.023 (95% CI, 1.003 to 1.043); ALRI, 1.050 (95% CI, 1.026 to 1.076); COPD, 1.114 (95% CI, 1.072 to 1.157); T2DM, 1.046 (95% CI, 1.007 to 1.086); and LC, 0.972 (95% CI, 0.948 to 0.996). Excess deaths attributable to long-term PM2.5 exposure were estimated at 4,888 (95% CI, 2,304 to 7,323) in 2010 and 5,179 (95% CI, 2,585 to 7,648) in 2019.
CONCLUSIONS
Although PM2.5 levels in Korea have shown a declining trend over the past decade, mortality among older adults associated with long-term PM2.5 exposure has not significantly decreased, likely due to the rapid aging of the population.; Summary

Korean summary
2010–2019년 동안 대한민국 노인 536만 명 대상의 후향적 코호트 연구를 수행하였다. 장기적인 초미세먼지(PM2.5) 노출은 허혈성 심질환, 뇌졸중, 하기도 감염, 만성폐쇄성폐질환, 제2형 당뇨병으로 인한 사망 위험 증가와 관련성이 있었다. 연간 PM2.5 농도는 감소했으나, 고령화로 인해 PM2.5에 기인한 초과 사망은 2010년 4,888명에서 2019년 5,179명으로 증가하였다. 대기질 개선에도 불구하고 고령화로 인해 PM2.5로 인한 사망 부담은 여전히 중요한 공중보건 문제이다.

Key Message
A retrospective cohort of 5.36 million older adults was followed from 2010 to 2019 in Korea. Long-term PM2.5 exposure was associated with increased mortality from IHD, stroke, ALRI, COPD, and T2DM. Although annual PM2.5 concentrations declined, excess deaths rose from 4,888 in 2010 to 5,179 in 2019, largely driven by population aging. Despite improvements in air quality, the PM2.5-related mortality burden remains a significant public health concern due to population aging.

Association between humidifier disinfectant use duration and lung cancer development in Korea: Sungchan Kang, Jeong-In Hwang, Su Hwan Kim, Hyungryul Lim, Dong-wook Lee, Woojoo Lee, Jong Hun Kim, Sol Yu, Jungyun Lim, Younghee Kim, Kyoung-Nam Kim; Epidemiol Health. 2025;47:e2025023. Published online May 2, 2025; DOI: https://doi.org/10.4178/epih.e2025023

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
This study was conducted to assess the association between the duration of humidifier disinfectant use and lung cancer development.
METHODS
We analyzed data from 3,605 applicants registered for compensation from the Korean government due to health conditions related to humidifier disinfectant exposure. Among these individuals, 121 were diagnosed with lung cancer at least 4 years after their initial exposure (through December 2021). Hazard ratios (HRs) and 95% confidence intervals (CIs) for lung cancer incidence were estimated according to the duration of disinfectant use using Cox proportional hazards models.
RESULTS
Compared with <5 months of use, the HRs for lung cancer were 1.81 (95% CI, 0.41 to 7.97) for 5-14 months, 2.45 (95% CI, 0.58 to 10.41) for 15-29 months, and 4.61 (95% CI, 1.12 to 18.91) for ≥30 months. Using never smokers with <15 months of use as the reference category, the HRs were 2.97 (95% CI, 1.34 to 6.56) for never smokers with ≥15 months of use, 2.73 (95% CI, 0.94 to 7.95) for current or former smokers with <15 months of use, and 4.74 (95% CI, 1.94 to 11.61) for current or former smokers with ≥15 months of use.
CONCLUSIONS
Our study provides some of the first robust epidemiological evidence that prolonged humidifier disinfectant use contributes to lung cancer development. Future studies—particularly those including unexposed populations—are needed to confirm these findings.; Summary

Korean summary
* 장기간의 가습기 살균제 사용과 폐암 발생의 위험 간에는 정량적 연관성을 발견할 수 있었습니다. * 가습기살균제를 30개월 이상 사용했다고 응답한 사람들은, 가습기살균제를 5개월 미만 사용했다고 응답한 사람들과 비교하여 폐암 발생 위험이 4배 높았습니다.

Key Message
* There is a quantitative association between prolonged humidifier disinfectants use and the risk of lung cancer incidence. * Individuals reported they used humidifier disinfectants for more than 30 months had more than four times higher risk of lung cancer than those of individuals who reported they used humidifier disinfectants for less than five months.

Cohort profile

Cohort profile update: the Korean Cancer Prevention Study-II Biobank: Heejin Kimm, Keum Ji Jung, Wes Spiller, Yeun Soo Yang, So Young Kim, Min Young Park, Sun Mi Lee, Sun Ha Jee; Epidemiol Health. 2025;e2025040. Published online July 29, 2025; DOI: https://doi.org/10.4178/epih.e2025040 [Accepted]

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Abstract Summary PDF: Abstract
Chronic diseases such as cancer and cardiovascular disease have a substantial impact on mortality and global disease burden. The Korean Cancer Prevention Study-II (KCPS-II) biobank was established to investigate these chronic diseases, with a particular focus on metabolic risk factors. Recently, genetic information reflecting diverse ancestries has been incorporated to support a precision medicine approach. These data can be leveraged to identify variation in causal effects among different ancestral groups, thereby informing the development of more effective, ancestry-specific treatments. From 2004 to 2013, baseline data were collected from 156,701 individuals aged 20–85 years, recruited from 18 health promotion centres across South Korea. Outcome data are routinely obtained from Statistics Korea (mortality data), the National Cancer Centre (cancer registry data), and the National Health Insurance Service (morbidity data). Additionally, new participants have been enrolled since 2022 as part of an ongoing expansion. This population-based cohort, enriched with genetic data, provides a robust foundation for research aimed at elucidating causal relationships in chronic disease.; Summary

Korean summary
· 한국 암 예방 연구 II 바이오 뱅크에는 한국 전역의 18개 건강 검진 센터에서 모집한 20~85세의 156,701명의 참여자가 포함되어 있다. · 모집 시 기준 측정에는 사회 경제적, 병력, 행동적, 생리적 및 혈액 샘플 데이터가 포함되어 있으며, 이들의 유전 분석이 완료되었다. · 한국 암 예방 연구 II는 현재 참여자를 모집하고 있는 진행 중인 코호트이며, 사망률 외에도 심혈관 및 암 이환율을 포함한 2차 자료 연계를 통해 후속 데이터를 사용할 수 있다. · 본 코호트를 통해 한국인의 역학 자료와 유전 자료를 이용하여 질병에 대한 매커니즘을 확인하고 질병 예방 및 극복에 대한 과학적 근거를 창출할 것으로 기대한다.

Key Message
· The Korean Cancer Prevention Study II (KCPS-II) Biobank comprises 156,701 adults aged 20–85 years, recruited from 18 health examination centers nationwide. · Baseline data include socioeconomic, medical history, behavioral, physiological, and blood sample information, with completed genetic analyses. · KCPS-II is an ongoing cohort with follow-up through linkage to secondary data on mortality, cardiovascular events, and cancer incidence. · This resource enables the integration of epidemiological and genetic data to investigate disease mechanisms and provide scientific evidence for prevention and control in the Korean population.

Cohort Profile

The 2019 Rio Grande birth cohort: profile of a Brazilian 5-year study on mental health conditions: Rafaela Costa Martins, Francine dos Santos Costa, Cauane Blumenberg, Thais Martins-Silva, Romina Buffarini, Juraci Almeida Cesar, Christian Loret de Mola; Epidemiol Health. 2025;47:e2025039. Published online July 21, 2025; DOI: https://doi.org/10.4178/epih.e2025039

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Abstract Summary PDF Supplementary Material: Abstract
We established the 2019 Rio Grande birth cohort to investigate the life course epidemiology of mental health and its intergenerational transmission. In 2019, we systematically identified all hospital births in the city of Rio Grande, located in Southern Brazil. Mothers who delivered a singleton liveborn child were administered a standardized, face-to-face questionnaire. In 2020, we conducted 2 follow-up assessments (WebCOVID-19 1 and 2), a third in 2021-22 (WebCOVID-19-3), and a fourth in 2023-24 (WebPOST-COVID). Across these follow-ups, we collected data on socio-demographic, environmental, and behavioral factors pertaining to both mother and child, as well as maternal mental health. Child mental health and development were specifically evaluated during the fourth follow-up. At baseline, 2,051 mothers were interviewed. Response rates for the online follow-ups were 54.1%, 51.1%, 48.7%, and 34.6%, respectively. In WebCOVID-19-3, the highest prevalence rates for depression (34.7%) and anxiety (33.1%) were observed. This cohort provides novel insights into maternal mental health, child development, and post-coronavirus disease 2019 behaviors, emphasizing culturally specific risk factors. Our findings are based on both published and ongoing studies. Data may be requested upon reasonable request.; Summary

Key Message
The 2019 Rio Grande Birth Cohort is a prospective study that has been following over 2,000 mothers and their children since 2019. It is designed specifically to understand the intergenerational transmission of mental health problems. The cohort's unique design combines detailed face-to-face questionnaires at baseline with remote, web-based follow-ups, and serves as a comprehensive overview of the cohort's methodology, data collection instruments, and study design, demonstrating its potential to generate valuable insights into maternal and child health.

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